Addressing the Ethical, Legal and Social Issues Raised by Voting Persons with Dementia
This article addresses an emerging policy problem in the United States participation in the electoral process by citizens with dementia. At present, health care professionals, family caregivers, and long-term care staff lack adequate guidance to decide whether individuals with dementia should be precluded from or assisted in casting a ballot. Voting by persons with dementia raises a series of important questions about the autonomy of individuals with dementia, the integrity of the electoral process, and the prevention of fraud. Three subsidiary issues warrant special attention: development of a method to assess capacity to vote; identification of appropriate kinds of assistance to enable persons with cognitive impairment to vote; and formulation of uniform and workable policies for voting in long-term care settings. In some instances, extrapolation from existing policies and research permits reasonable recommendations to guide policy and practice. However, in other instances, additional research is necessary.
OBJECTIVE: The right to vote can be abrogated when persons become incompetent to cast a ballot. This applies particularly to people with Alzheimer’s disease, who at some point will lose capacity. A 2001 federal court decision offered the first clear criteria ("Doe voting capacity standard") for determining voting competence, focused on understanding the nature and effect of voting and on the ability to choose. This article explores how persons with Alzheimer’s disease perform on these criteria.
Modern democratic nations have designed electoral systems to achieve two fundamental goals: increasing enfranchisement and voting, and, assuring the integrity of the vote. Efforts to achieve these two objectives can generate a tension between them. As an example, postal voting (also called absentee balloting) has the benefit of allowing persons who cannot easily reach a polling place to vote from remote locations at some time prior to the day of the election. This is especially valuable to persons with disabilities that limit their ability to travel. But postal voting also increases the risk of fraud. Specifically, these ballots can be stolen and either cast by other people or destroyed. The magnitude of this problem can increase in congregate living settings where multiple voters cast absentee ballots. In short, there is a trade-off between an effort to enhance enfranchisement, in this case by postal voting, while at the same time assuring the integrity of the electoral process.
To ascertain the need for and inform development of guidelines for voting in long-term care settings, we conducted a telephone survey of Philadelphia nursing (n=31) and assisted living (n=20) settings following the 2003 election. Substantial variability existed in procedures used for registration and voting, in staff attitudes, and in the estimated proportion of residents who voted (29%+28, range 0 to 100%). Residents who wanted to vote were unable to do so at nearly one-third of sites, largely due to procedural problems. Nearly two-thirds of facilities indicated they assessed residents’ voting capacity before the election. However, methods differed and may have disenfranchised residents who were actually competent to vote. Current procedures in many facilities fail to protect voting rights. These data suggest that rights might be better protected if election officials took charge of registration, filing absentee ballot requests, ballot completion, and trained LTC facility staff on voters’ rights and reasonable accommodations.
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